Lung protective ventilatory strategies in very low birth weight infants

Surfactant therapy and mechanical ventilation using conventional or high-frequency ventilation have been the standard of care in the management of RDS, the most common respiratory diagnosis in preterm infants. Despite these treatments, bronchopulmonary dysplasia (BPD) continues to remain as a major morbidity in very low birth weight infantsand is associated with clinically important short- and long-term adverse pulmonary and nonpulmonary outcomes. . In this review, the different ventilation strategies current in use are presented and discussed.
High-frequency and conventional ventilatory techniques have been extensively evaluated in the management of RDS in preterm infants. Overall, results of several clinical trials suggest that when an optimal lung volume strategy is used there appears not to be a significant difference in pulmonary outcome between the two modalities.
Noteworthy, it has been suggested that lung injury is directly related to the duration of invasive ventilation via the endotracheal tube. Therefore, clinicians are increasingly using noninvasive ventilation with nasal continuous positive airway pressure (NCPAP) or noninvasive positive pressure ventilation (NIPPV) to protect the preterm infant's lungs.
Noninvasive ventilation appears to be beneficial in the management of apnea of prematurity, for the prevention of extubation failures, and in the initial management of RDS. Lung protective ventilatory strategy may involve noninvasive ventilation as a primary therapy or following surfactant administration in very preterm infants with RDS. Studies using NCPAP or NIPPV have shown to decrease postextubation failures and a trend toward reduced risk of BPD.
NCPAP patient interfaces commonly used include single or binasal prongs as well as nasopharyngeal prongs. Current evidence suggests that short binasal prongs are more effective than single nasal prongs to deliver NCPAP.
When directly comparing NCPAP and NIPPV, it has been shown that NIPPV significantly decreased postextubation failures compared to NCPAP and is associated with an excellent adverse effect profile. Moreover, two randomized studies using synchronized NIPPV at the time of extubation showed significant reduction in extubation failures compared to NCPAP. Initial steps in the management of preterm infants may also include sustained inflation to establish functional residual capacity, followed by noninvasive ventilation to minimize lung injury and subsequent development of BPD.
It must be emphasized, however, that at present there are guidelines for the use of noninvasive ventilation in preterm infants. More studies are needed before noninvasive ventilation becomes a routine lung protective strategy.
In summary, based on current evidence, when an optimal lung volume strategy is used, there does not appear to be any significant difference between high-frequency and conventional ventilatory techniques. On the other hand, noninvasive ventilation using NCPAP or NIPPV has been shown to significantly decrease BPD incidence. In particular, NIPPV appears to have some advantages when compared to NCPAP. Even if guidelines are still to be developed, the use of noninvasive ventilation as a primary mode or following surfactant administration seems to be associated with improved outcomes in preterm infants with RDS.

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